3106: Week 7

Warm, Moist Compresses

Warm, moist compresses improve circulation, relieve edema, and promote consolidation of purulent drainage. A compress is a piece of gauze dressing moistened in a prescribed warmed solution. Heat from warm compresses dissipates quickly. To maintain a constant temperature, you need to change the compress often. You can use a layer of plastic wrap or a dry towel to insulate the compress and retain heat. Moist heat promotes vasodilation and evaporation of heat from the surface of the skin. For this reason a patient can feel chilly. Always try to control drafts within the room, and keep the patient covered with a blanket or robe.

The four phases involved in the healing process of a full-thickness wound are:

hemostasis, inflammation, proliferation, and maturation.

Three pressure-related factors contribute to pressure ulcer development:

(1) pressure intensity, (2) pressure duration, and (3) tissue tolerance.

Wound Care

-Cleaning skin and drain sites -Clean per Dr. orders -Clean from least contaminated to the surrounding skin -When irrigating, allow the solution to flow from the least to most contaminated area

Nursing Process: Implementation Skin

-Health promotion -Prevention of pressure ulcers -Topical skin care and incontinence management -Positioning -Support surfaces -Acute Care -Management of pressure ulcers -Wound management -Debridement -Education -Nutritional status -Protein status -Hemoglobin -First aid for wounds -Hemostasis -Cleaning -Protection -Dressings -Suture/staple care -Drainage evacuation -Bandages and dressings

Complications of wound healing are caused by:

-Hemorrhage -Infection -Dehiscence -Evisceration

Risk factors for pressure ulcer development

-Impaired sensory perception -Impaired mobility -Alteration in LOC -Shear -Friction -Moisture

Dressing Changes

-Know type of dressing, and supplies needed. -Prepare the patient for a dressing change. -Review previous wound assessment notes. -Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change. -Describe procedure steps to lessen patient anxiety. -Gather all supplies. -Recognize normal signs of healing. -Answer questions about the procedure or wound. -Comfort measures -Administer analgesic medications 30 to 60 minutes before dressing changes -Carefully remove tape -Gently clean wound edges -Carefully manipulate dressings and drains to minimize stress on sensitive tissues -Turn and position patient carefully

Factors influencing pressure injury formation and wound healing are:

-Nutrition -Tissue perfusion -Infection -Age -Psychosocial impact of wounds

Nursing diagnoses associated with impaired skin integrity and wounds:

-Risk for infection -Imbalanced nutrition: less than body requirements -Acute or chronic pain -Impaired physical mobility -Impaired skin integrity -Risk for impaired skin integrity -Ineffective peripheral tissue perfusion -Impaired tissue integrity

Pressure injuries are classified as:

-Stage 1: Non-blanchable erythema of intact skin -Stage 2: Partial-thickness skin loss with exposed dermis -Stage 3: Full-thickness skin loss with visible adipose fat. -Stage 4: Pressure Injury: Full-thickness skin and tissue loss -Deep tissue injury -Unstageable pressure ulcer

The following three principles are important when cleaning an incision or the area surrounding a drain:

1. Clean in a direction from the least contaminated area, such as from a wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to most contaminated area

Changing Dressings

A health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. An order to "reinforce dressing prn" (add dressings without removing the original one) is common right after surgery, when the health care provider does not want accidental disruption of the suture line or bleeding. The medical or operating room record usually indicates whether drains are present and from which body cavity they drain. Always know the type of wound and dressing, the presence of underlying drains or tubing, and the type of supplies needed for wound care. Poor preparation causes a break in aseptic technique or accidental pulling of wound tissue or dislodgement of a drain. Your judgment in modifying a dressing-change procedure is important during wound care, particularly if the character of a wound changes. Notifying the health care provider of any change is essential.

Sitz Baths

A patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, or vaginal inflammation benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The patient sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water. Immersing the entire body causes widespread vasodilation and nullifies the effect of local heat application to the pelvic area. The desired temperature for a sitz bath depends on whether the purpose is to promote relaxation or to clean a wound. It is often necessary to add warm or cool water during the procedure, which normally lasts 20 minutes, to maintain a constant temperature. Agency procedure manuals recommend safe water temperatures. A disposable sitz basin contains an attachment resembling an enema bag that allows gradual introduction of additional water. Prevent overexposure of patients by draping bath blankets around their shoulders and thighs and controlling drafts. A patient should be able to sit in the basin or tub with feet flat on the floor and without pressure on the sacrum or thighs. Because exposure of a large part of the body to heat causes extensive vasodilation, assess the pulse and facial color and ask whether the patient feels light-headed or nauseated.

Pressure injury

A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device or other device. The injury can present as intact skin, a blister, or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.

Pressure Ulcer

A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. •Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. •If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results.

Comfort Measures

A wound is often painful, depending on the extent of tissue injury, and wound care often requires the use of well-timed analgesia before any wound procedure. Administer analgesic medications 30 to 60 minutes before dressing changes, depending on the time of peak action of a drug. In addition, several techniques are useful in minimizing discomfort during wound care. Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound.

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated. B. migrate across the incision. C. appear slightly pink. D. slightly overlap each other.

A. are approximated.

Assessment for Temperature Tolerance

Before applying heat or cold therapies, assess a patient's physical condition for signs of potential intolerance to heat and cold. First observe the area to be treated. Assess the skin, looking for any open areas such as alterations in skin integrity (e.g., abrasions, open wounds, edema, bruising, bleeding, or localized areas of inflammation) that increase a patient's risk for injury. Because a health care provider commonly orders heat and cold applications for traumatized areas, the baseline skin assessment provides a guide for evaluating skin changes that can occur during therapy. Assess neurological function, testing for sensation to light touch, pinprick, and mild temperature variations. Sensory status reveals the ability of a patient to recognize when heat or cold becomes excessive. Assess a patient's mental status to be sure that he or she can correctly communicate any issues with the hot or cold therapy. Level of consciousness influences the ability to perceive heat, cold, and pain. If a patient is confused or unresponsive, the nurse needs to make frequent observations of skin integrity after therapy begins.

Packing a Wound

The first step in packing a wound is to assess its size, depth, and shape. These characteristics are important in determining the size and type of dressing used to pack a wound. The dressing needs to be flexible and in contact with the entire wound surface. Make sure that the type of material used to pack the wound is appropriate. If gauze is the appropriate dressing material, saturate with the ordered solution, wring out, unfold, and lightly pack into the wound. The entire wound surface needs to be in contact with part of the moist gauze dressing. It is important to remember not to pack a wound too tightly. Overpacking causes pressure on the wound bed tissue. Pack the wound only until the packing material reaches the surface of the wound; there should never be so much packing material that it extends higher than the wound surface. Packing that overlaps onto the wound edges causes maceration of the skin surrounding the wound.

Friction

The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called friction. Unlike shear injuries, friction injuries affect the epidermis or top layer of the skin (superficial skin loss). The denuded skin appears red and painful and is sometimes referred to as a sheet burn. A friction injury occurs in patients who are restless, in those who have uncontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes or transfer to a stretcher. This type of injury should not be classified as a pressure injury. Friction leads to pressure injury formation only when it causes harmful shear stress and strain.

Age and wounds

The physiological changes associated with aging affect all phases of wound healing. A decrease in the functioning of macrophages leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization.

Moisture

The presence and duration of moisture on the skin increases the risk of pressure injury. Moisture reduces the resistance of the skin to other physical factors such as pressure, friction, or shear. Prolonged moisture softens skin, making it more susceptible to damage. The term moisture-associated skin damage (MASD) is defined as inflammation and erosion to the skin caused by prolonged exposure to various sources of moisture, including wound drainage, urine or stool, perspiration, wound exudate, mucus or saliva

Proliferative Stage

The proliferative phase begins with the appearance of new blood vessels as reconstruction progresses and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. -Fibroblasts are present in this phase. Fibroblasts are the cells that synthesize collagen, providing the matrix for granulation. -Collagen provides strength and structural integrity to a wound. During this period the wound contracts to reduce the area that requires healing.

Psychosocial Impact of Wounds

The psychosocial impact of wounds on the physiological process of healing is unknown. Body image changes often impose a great stress on a patient's adaptive mechanisms. They also influence self-concept and sexuality. Factors that affect a patient's perception of a wound include: location, the presence of scars, stitches, drains (often needed for weeks or months), odor from drainage, and temporary or permanent prosthetic devices.

Why should we assess the type of tissue in the wound base?

To provide information to help plan appropriate interventions. The assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal. Black, brown, tan, or necrotic tissue is eschar, which needs to be removed before healing can proceed.

Securing Dressings

Use tape, ties, or a secondary dressing to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient's level of activity. You will most often use strips of tape to secure dressings. Nonallergenic paper and silicone tapes minimize skin reactions. Common adhesive tape adheres well to the surface of the skin, whereas elastic adhesive tape compresses closely around pressure bandages and permits more movement of a body part. Skin sensitive to adhesive tape becomes severely inflamed and denuded and, in some cases, even sloughs when the tape is removed. It is important to assess the condition of the skin under tape at each dressing change.

Skin Nursing Assessment Questions

Sensation • Do you have tingling, decreased feeling, or absent feeling in your extremities? • Can you feel pressure when sitting or lying down? • When preparing a bath is your skin sensitive to heat or cold? Mobility • Do you have any physical limitations, injury, or paralysis that limits your ability to move on your own? • Can you change your position easily? • Tell me about any pain you have when you walk, sit down, or move about your home. Continence • Do you have any problems or accidents leaking urine or stool? • What help do you need when using the toilet? In what way? • How often do you need to use the toilet? During the day? At night? Presence of Wound • What do you believe caused your wound? • When did the wound occur? Where is it located? • When did you receive a tetanus shot? • What has happened to this wound since it occurred? What were the changes and what caused them? • What have you done to treat the wound? Which treatments, activities, or care have slowed or helped the wound to heal? • Do you have any pain, itching, or other symptoms with the wound? How are you managing the itching, and what works best for you? • Who helps you care for your wound?

Pain and wounds

Significant research has been conducted in the study of pain in surgical patients with wounds. The routine assessment of pain in surgical patients is critical to selecting appropriate pain management therapies and to determine a patient's ability to progress toward recovery. The WOCN has recommended that assessment and management of pain also be included in the care of patients with pressure injuries. Use standard pain assessment tools to measure pain acuity, and be thorough in assessing the character of a patient's pain. Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure injury risk.

Dehiscence

When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence. partial or total separation of wound layers

Drainage Evacuation

When drainage interferes with healing, evacuation of the drainage is achieved by using either a drain alone or a drainage tube with continuous suction. You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies, around drain sites with significant drainage for skin protection. The skin barriers are soft material applied to the skin with adhesive. Drainage flows on the barrier but not directly on the skin. Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, immediately reset the evacuator to apply suction, and record the output.

Evisceration

With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency. Immediately place damp sterile gauze over site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery. The displacement of organs outside of the body.

Infection and wounds

Wound infection prolongs the inflammatory phase; delays collagen synthesis; prevents epithelialization; and increases the production of proinflammatory cytokines, which leads to additional tissue destruction. Indications that a wound infection is present include the presence of purulent drainage; change in odor, volume, or character of wound drainage; redness in the surrounding tissue; fever; or pain.

Tertiary intention wound healing

Wound is left open for several days, then wound edges are approximated.

blanchable hyperemia

You assess an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanchable hyperemia .

The process of any of these factors will cause wound deterioration:

-Predictive measures - a low score on the Braden scale predicts higher chances or pressure ulcer development. -Decreased mobility -Poor nutritional status -Moisture/incontinence -Pain

tissue perfusion

Oxygen fuels the cellular functions essential to the healing process; therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing. Patients with diabetes and peripheral vascular disease are at risk for poor tissue perfusion because of poor circulation. Oxygen requirements depend on the phase of wound healing (e.g., chronic tissue hypoxia is associated with impaired collagen synthesis and reduced tissue resistance to infection).

Serosanguineous

Pale, pink, watery of clear and red fluid

Stage 2 Pressure Ulcer

Partial-thickness skin loss with exposed dermis •Partial-thickness. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury.

Stage 4 Pressure Ulcer

Pressure Injury: Full-thickness skin and tissue loss •Full-thickness Tissue Loss. Full-thickness tissue loss with exposed bone, tendon, or muscle. Subcutaneous fat may be visible and slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location.

Economic Consequences of Pressure Injuries

Pressure injuries are a continual problem in acute and restorative care settings, especially in patients 65 years and older . Paralysis and spinal cord injury are common preexisting conditions among younger adults with primary diagnosis of pressure injuries. Older adults admitted to acute and long-term facilities are a vulnerable population. Although the cost to provide pressure injury prevention to patients at risk can impact health care services' budgets, the costs to treat a severe pressure injury are substantially higher. When a pressure injury occurs, the length of stay in a hospital and the overall cost of health care increase. These injuries are also costly to patients in terms of disability, pain, and suffering. About 1.6 million patients each year in acute care settings develop pressure injuries, representing a cost of $11 billion to $17.2 billion to the US health care system. The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008, whereby hospitals no longer receive reimbursement for care related to stage 3 and 4 pressure injuries that occur during a hospitalization. Guidelines such as the WOCN Guidelines help reduce or eliminate the occurrence of pressure injuries and prevent the expenses that will not be reimbursed.

Braden Scale

The Braden scale was developed based on risk factors in nursing home patient populations. It is used to predict the patients are risk for developing pressure ulcers. It is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development.

Effects of Cold Application

The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. Skin tissues freeze from exposure to extreme cold.

Role of Selected Nutrients in Wound Healing

Calories Fuel for cell energy "Protein protection" 35-40 kcal/kg/day or enough to maintain positive nitrogen balance Protein Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function 1-1.5 g/kg/day or enough to maintain positive nitrogen balance Poultry, fish, eggs, beef Vitamin C (ascorbic acid) Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant 100-1000 mg/day Need long time to develop clinical scurvy from vitamin C deficiency Low toxicity Citrus fruits, tomatoes, potatoes, fortified fruit juices Vitamin A Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation 1600-2000 retinol equivalents per day Supplement if deficient 20,000 units × 10 days Green leafy vegetables (spinach), broccoli, carrots, sweet potatoes, liver Can reverse steroid effects on skin and delayed healing Vitamin E No known role in wound healing, antioxidant None Fish, oysters, liver, dark meat, eggs, legumes Zinc Collagen formation, protein synthesis, cell membrane and host defenses 15-30 mg Correct deficiencies No improvement in wound healing with supplementation unless zinc deficient Use with caution—large doses can be toxic May inhibit copper metabolism and impair immune function Vegetables, meats, legumes Fluid Essential fluid environment for all cell function 30-35 mL/kg/day Increase by another 10-15 mL/kg if patient is on an air-fluidized bed Use noncaffeine, nonalcoholic fluids without sugar Water is best—6-8 glasses/day

Serous

Clear, watery plasma

cold therapy

Cold therapy refers to the superficial application of cold to the surface of the skin, with or without compression and with or without a mechanical recirculating device to maintain cold temperatures. Cold therapy is designed to treat the localized inflammatory response of an injured body part that presents as edema, hemorrhage, muscle spasm, or pain. Improvement to joint mobility following cold therapy is related to reducing pain and swelling, inhibiting muscle spasm, and reducing muscle tension. Cold therapy most commonly is used immediately after soft tissue and musculoskeletal injuries such as sprains or strains; however, it has been used in the postoperative setting with patients who have undergone orthopedic surgeries, spinal fusion, and lumbar discectomy. Research trials of cold therapy have been inconsistent and frequently found no differences compared with no cold therapy in postoperative pain or analgesic use

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has no odor. B. a culture is negative. C. the edges reveal the presence of fluid. D. it shows purulent drainage coming from the incision site.

D. it shows purulent drainage coming from the incision site.

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. protection from the external environment. D. moisture needed for wound healing.

D. moisture needed for wound healing.

Cultural Aspects of Care Impact of Skin Color

Detecting cyanosis and other changes in skin color in patients is an important clinical skill. However, this detection becomes a challenge in patients with darkly pigmented skin. Color differentiation of cyanosis varies according to skin pigmentation. In patients with darkly pigmented skin, you need to know the individual's baseline skin tone. • Patients with darkly pigmented skin cannot be assessed for pressure injury risk by examining only skin color • Use natural lighting • Assess for changes in sensation, temperature, or tissue consistency, which may precede visual skin changes • Examine body sites with the least melanin such as under the arm for underlying color identification • Palpate surrounding tissues to identify any changes in temperature, edema, or tissue consistency between area of injury or suspected injury and normal tissue • Circumscribed area of intact skin may be warm to touch. • Localized heat (inflammation) is detected by making comparisons to surrounding skin. • Edema may occur with induration of more than 15 mm in diameter, and skin may appear taut and shiny

Hemostasis stage

During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair.

Primary intention wound healing

Edges are approximate

Secondary intention wound healing

Edges are not approximated

Skin

Epidermis •Top layer of skin Dermis •Inner layer of skin •Collagen Dermal-epidermal junction •Separates dermis and epidermis

Unstageable pressure ulcer

Full-thickness Skin or Tissue Loss—Depth Unknown. Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.

Stage 3 Pressure Ulcer

Full-thickness skin loss with visible adipose fat. •Full-thickness Skin Loss. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.

Gauze sponges

Gauze sponges are the oldest and most common dressing. They are absorbent and are especially useful in wounds to wick away wound exudate. Gauze is available in different textures and various lengths and sizes; the 4 × 4 is the most common size. Gauze can be saturated with solutions and used to clean and pack a wound. When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out (leaving the gauze only moist), unfolded, and lightly packed into the wound. Unfolding the dressing allows easy wicking action. The purpose of this type of dressing is to provide moisture to the wound yet to allow wound drainage to be wicked into the dry cover gauze pad.

Hydrogel dressing

Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings are indicated for use in partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. They debride necrotic tissue by softening the necrotic area. They can be very useful in painful wounds because they are very soothing to a patient and do not adhere to the wound bed and thus cause little pain during removal. A disadvantage is that some hydrogels require a secondary dressing and you must take care to prevent periwound maceration. Hydrogels also come in a tube; thus you are able to squirt the gel directly into the wound base.

Nonblanchable erythema

If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.

Inflammation stage

In the inflammation stage, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and causes movement/migration of serum and white blood cells into the damaged tissues

Irrigation

Irrigation Irrigation is a way of cleaning wounds. Use an irrigation syringe to flush the wound with a constant low-pressure flow of solution. The gentle washing action of the irrigation cleanses a wound of exudate and debris. Irrigation is particularly useful for open, deep wounds; wounds involving an inaccessible body part such as the ear canal; or when cleaning sensitive body parts such as the conjunctival lining of the eye. Irrigation of an open wound requires sterile technique. Use a 35-mL syringe with a 19-gauge soft angiocatheter to deliver the solution. This irrigation system has a safe pressure and does not damage healing wound tissue. It is important to never occlude a wound opening with a syringe because this results in the introduction of irrigating fluid into a closed space. The pressure of the fluid causes tissue damage and discomfort and possibly forces infection or debris into the wound bed. Always irrigate a wound with the syringe tip over but not in the drainage site. Make sure that fluid flows directly into the wound and not over a contaminated area before entering the wound.

Pressure Duration

Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure. Both types of pressure cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. Clinical implications of pressure duration include evaluating the amount of pressure (checking skin for nonblanching hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches).

Maturation stage

Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. -The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. -Collagen fibers undergo remodeling or reorganization before assuming their normal appearance. Usually, scar tissue forms and it contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals, the scar tissue may be more highly pigmented than surrounding skin.

heat therapy

Moist heat applications are therapeutically beneficial in increasing muscle and ligament flexibility; promoting relaxation and healing; and relieving spasm, joint stiffness, and pain. Moist heat has many indications; however, it is most commonly used following the acute phase of a musculoskeletal injury and during and after childbirth, surgery, and superficial thrombophlebitis. Moist heat applications include warm compresses and commercial moist heat packs, warm baths, soaks, and sitz baths. Dry heat is also used to reduce pain and increase healing by increasing blood flow in tissues and can be used at a low level for a longer period with little chance of tissue injury

Hemorrhage

bleeding from a wound site, is normal during and immediately after initial trauma. Hemorrhage occurs externally or internally. -You detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. -A hematoma is a localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. -External hemorrhaging is obvious. Observe all wounds closely, particularly surgical wounds, in which the risk of hemorrhage is great during the first 24 to 48 hours after surgery or injury.

Sanguineous

bright red, indicates active bleeding

Full-thickness wound

extends into the subcutaneous layer and the depth and tissue type will vary depending on body location. -heal by hemostasis, inflammatory, proliferative, and maturation

Wound infection

is present when the microorganisms invade the wound tissues. -The local clinical signs of wound infection can include erythema, increased amount of wound drainage, change in appearance of the wound drainage, warmth, pain, or edema. The patient has a fever, tenderness, and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is purulent, which causes a yellow, green, or brown color, depending on the causative organism.

Blanching

occurs when the normal red tones of the light-skinned patient are absent. When checking for pressure injuries in patients with dark pigmented skin, be aware that dark skin may not show the blanch response. Therefore inspect the pressure area with an adjacent or opposite area of the body for comparison. . Extended pressure occludes blood flow and nutrients and contributes to cell death. •The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.

Wounds can be classified by the extent of tissue loss:

partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis).

Debridement

removal of foreign material and dead or damaged tissue from a wound Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. The method of debridement depends on which is most appropriate for a patient's condition and goals of care. It is important to remember that during the debridement process some normal wound observations include an increase in wound exudate, odor, and size. You need to assess and prevent or effectively manage pain that occurs with debridement. Plan to administer an ordered analgesic 30 minutes before debridement.

Partial-thickness wounds

shallow in depth, moist, and painful, and the wound base generally appears red. -heal by the inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

Epidermis

top layer of skin •The epidermis has several layers within it. The stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface.

Examples of patients who are at risk for the development of pressure injuries include the following:

• Older adults, those who have experienced trauma • Those with spinal-cord injuries (SCI) • Those who have sustained a fractured hip • Those in long-term homes or community care, the acutely ill, or those in a hospice setting • Individuals with diabetes • Patients in critical care settings

Dressing Considerations

• Clean the wound and periwound area at each dressing change, minimizing trauma to the wound • Use a dressing that continuously provides a moist environment. • Perform wound care using topical dressings as determined by a thorough assessment. • No specific studies have proven an optimal dressing type for pressure injuries • Choose a dressing that keeps the periwound skin dry while keeping the injury bed moist. • Choose a dressing that controls exudate but does not desiccate the injury bed. • The type of dressing may change over time as the pressure injury heals or deteriorates. The wound should be monitored at every dressing change and regularly assessed to determine whether modifications in the dressing type are needed • Consider caregiver time, ease of use, availability, and cost when selecting a dressing.

Nutrition and wounds

Normal wound healing requires proper nutrition. Deficiencies in any of the nutrients result in impaired or delayed healing . Physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals zinc and copper. Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested in food. Vitamin C is necessary for synthesis of collagen. Vitamin A reduces the negative effects of steroids on wound healing. Trace elements are also necessary (i.e., zinc for epithelialization and collagen synthesis and copper for collagen fiber linking).

negative-pressure wound therapy (NPWT)

One treatment modality for wounds is negative-pressure wound therapy (NPWT) or vacuum-assisted closure (one brand name is V.A.C.). NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid . The vacuum-assisted closure (V.A.C.) is a device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together. NPWT supports wound healing by reduction of edema and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion. Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden. The V.A.C. Instill system allows intermittent instillation of fluids into a wound and liquefies infectious material and wound debris, especially in wounds not responding to traditional NPWT

Wound classification

•A wound is a disruption of the integrity and function of tissues in the body. Understanding the etiology of a wound is important because the treatment for it varies, depending on the underlying disease process. •There are many ways to classify wounds. Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, and descriptive qualities of the wound tissue such as color. •Wound classification enables a nurse to understand the risks associated with a wound and implications for healing •Wounds can be classified by the extent of tissue loss: partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis). •Partial-thickness wounds are shallow in depth, moist, and painful, and the wound base generally appears red. •A full-thickness wound extends into the subcutaneous layer and the depth and tissue type will vary depending on body location.

Assessing Pressure Ulcers

•Assess pressure ulcers at regular intervals using systematic parameters to evaluate wound healing, plan appropriate interventions, and evaluate progress. Assessment includes wound location, depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. •Pressure ulcer staging describes the pressure ulcer depth at the point of assessment. Pressure ulcers do not progress from a Stage III to a Stage I. A Stage III ulcer demonstrating signs of healing is described as a healing Stage III pressure ulcer. •Use a disposable wound-measuring devices to obtain the measurement of width and length. Measure depth by using a cotton-tipped applicator in the wound bed. •Wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Examine the periwound area for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration.

Nursing Process: Assessment Skin

•Continually assess skin for signs of breakdown and/or ulcer development •Focusing on specific elements, such as a patient's level of sensation, movement, and continence status, helps guide the skin assessment. •Continually assesses the skin for signs of skin breakdown and/or ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. •Pay particular attention to areas located over bony prominences; next to medical devices; under casts, traction, splints, braces, collars, or other orthopedic devices. The frequency of pressure checks depends on the schedule of appliance application and the response of the skin to the external pressure.

Risk factors for pressure ulcers

•Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves. •Shear is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. •Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. •The presence and duration of moisture on the skin reduce the skin's resistance and may cause pressure ulcers •Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. •Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. •Patients who are unable to independently change position are at risk because they cannot change or shift off bony prominence areas.

Purposes of dressings

•Protects from microorganisms •Aids in hemostasis •Promotes healing by absorbing drainage or debriding a wound •Supports wound site •Promotes thermal insulation •Provides a moist environment

Dermis

•The dermis provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. The dermis is made of collagen, blood vessels, and nerves. •Inner layer of skin •Collagen

Cleaning Skin and Drain Sites

Although a moderate amount of wound exudate promotes epithelial cell growth, some health care providers order cleaning a wound or drain site if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin. Wound cleaning requires good hand hygiene and aseptic techniques. You can use irrigation to remove debris from a wound.

Self-adhesive, transparent film

Another type of dressing is a self-adhesive, transparent film that traps moisture over a wound, providing a moist environment to encourage epithelial cell growth. A transparent dressing adheres to undamaged skin, does not need a secondary dressing, and permits viewing of the wound. It is ideal for small superficial wounds such as a stage 1 pressure injury or a partial-thickness wound. Use a film dressing as a secondary dressing and for autolytic debridement of small wounds. It serves as a barrier to external fluids and bacteria but still allows the wound surface to "breathe" because oxygen passes through the transparent dressing. This dressing promotes a moist environment to encourage epithelial cell growth. It adheres to undamaged skin, does not need a secondary dressing, and permits viewing of the wound.

Mobility and wounds

Assessment includes documenting the baseline level of mobility and the potential effects of impaired mobility on skin integrity. Documenting assessment of mobility includes obtaining data regarding the quality of muscle tone and strength. For example, determine whether the patient is able to lift his or her weight off the sacral area and roll the body to a side-lying position. Some patients have inadequate range of motion to move independently into a more protective position. Finally, assess a patient's activity tolerance to determine whether the patient can be transferred to a chair or ambulated more often to relieve pressure from lying down.

Nutritional Status and wounds

An assessment of a patient's nutritional status is an integral part of the initial assessment data for any patient, especially one at risk for impaired skin integrity. The Joint Commission recommends nutritional assessment within 24 hours of admission. Weigh the patient and perform this measure more often for at-risk patients. A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 lb in a brief period are all signs of actual or potential nutritional problems. Assess the patient's mouth and teeth for oral sores and ill-fitting dentures that impact nutritional intake.

Deep tissue injury

Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones.

Bodily Responses to Heat and Cold

Exposure to heat and cold causes systemic and local responses. Systemic responses occur through heat-loss mechanisms (sweating and vasodilation) or mechanisms promoting heat conservation (vasoconstriction and piloerection) and heat production (shivering). Local responses to heat and cold occur through stimulation of temperature-sensitive nerve endings within the skin. This stimulation sends impulses from the periphery to the hypothalamus, which becomes aware of local temperature sensations and triggers adaptive responses for maintenance of normal body temperature. If alterations occur along temperature sensation pathways, the reception and eventual perception of stimuli are altered.

Hydrocolloid dressing

Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds; they are available in a variety of sizes and shapes. This type of dressing absorbs drainage through the use of exudate absorbers in the dressing; maintains wound moisture; slowly liquefies necrotic debris; and can be left in place for 3 to 5 days. In addition, hydrocolloid dressings are impermeable to bacteria and other contaminants, act as a preventive dressing for high-risk friction areas, and are self-adhesive and mold to the wound. The hydrocolloid dressing is useful on shallow-to-moderately deep dermal injuries. Hydrocolloid dressings cannot absorb drainage from heavily draining wounds, and some are contraindicated for use in full-thickness and infected wounds. Most hydrocolloids leave a residue in the wound bed that is easy to confuse with purulent drainage.

Effects of Heat Application

Generally heat is quite therapeutic, improving blood flow to an injured part. However, if it is applied for 1 hour or more, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. Periodic removal and reapplication of local heat restores vasodilation. Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering.

Nursing Process: Planning Skin

Goals and outcomes -Plan interventions according to •Risk for pressure ulcers •Type and severity of the wound •Presence of complications Setting priorities -Preventing pressure ulcers -Promoting wound healing Teamwork and collaboration is the key to wound healing.

Warm Soaks

Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution. Sometimes a soak is also accompanied by wrapping the body part in dressings and saturating them with the warmed solution. Position the patient comfortably, place waterproof pads under the area to be treated, and heat the solution to about 40.5° to 43°C (105° to 110°F). Pour solution into a clean or sterile basin or container, then immerse the body part. Cover the container and extremity with a towel to reduce heat loss. It is usually necessary to remove the cooled solution and add heated solution after about 10 minutes. The challenge is to keep the solution at a constant temperature. Never add a hotter solution while the body part remains immersed. After any soak dry the body part thoroughly to prevent maceration.

Body Fluids and wounds

It is important to prevent and reduce the patient's exposure to body fluids; when exposure occurs, provide meticulous hygiene and skin care. Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure injury formation. Some body fluids such as saliva and serosanguineous drainage are not as caustic, and the risk of skin breakdown from exposure to these fluids is low. However, exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Frequent exposure to urine and fecal contents increases patients' risk for incontinence-associated dermatitis (IAD). Additionally, exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. These fluids have digestive qualities that can irritate and break down the skin quickly.

Positioning

Positioning Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention. The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces. Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort. A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences. The WOCN guidelines recommend a 30-degree lateral position, which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions.

Tissue Tolerance

The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures. The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure: the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure. The second factor related to tissue tolerance is the ability of the underlying skin structures (blood vessels, collagen) to help redistribute pressure. Systemic factors such as poor nutrition, aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied pressure.

Stage 1 Pressure Ulcer

Non-blanchable erythema of intact skin •Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

Purulent

Thick, yellow, green, tan, or brown

Pressure Intensity

A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary. Therefore, when the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur. If the patient has reduced sensation and cannot respond to the discomfort of the ischemia, tissue ischemia, and tissue death result. The clinical presentation of obstructed blood flow occurs when evaluating areas of pressure. After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin turns red. The effect of this redness is vasodilation (blood vessel expansion), called hyperemia (redness).